Hysterectomy is removal of uterus. Depending on
the extent of removal of uterus and adjacent structures, the following types
are described.
·
Total hysterectomy -Removal of the entire uterus.
·
Subtotal hysterectomy -Removal of the body or corpus leaving behind the
cervix.
·
Panhysterectomy-Removal of the uterus along with removal of tubes and
ovaries of both sides.
·
Extended hysterectomy -panhysterectomy with removal of cuff of vagina.
·
Radical hysterectomy -Removal of the uterus, tubes and ovaries of both sides,
upper one -third of vagina, adjacent paramatreium and the draining lymph nodes.
INDICATIONS:-
·
Benign lesions ---a)Dysfunction uterine bleeding
b)
Fibroid uterus
c) Tubo -ovarian mass
d) Endometriosis
e) Adenomyosis
f) CIN
g) Endometrial hyperplasia
g) Endometrial hyperplasia
h) Ovarian tumour
i) Perimenopausal age
·
MALIGNANCY ---a)Carcinoma cervix
b) Carcinoma ovary
c) Carcinoma endomtrium
d) Uterine sarcoma
e) Choriocarcinoma
·
TRAUMATIC ---a)uterine perforation
b) Cervical tear
c) Rupture uterus
·
OBSTETRICAL---a)Atonic pph
b) Morbid adherent placenta
c)
Hyaditiform mole
d) <35 years
e) Septic abortion
·
Some considerations of hysterectomy :-
1)Age
and parity :An ideal condition is that the patient preferably be in the perimenopausal age group with family
completed .However ,the operation may have to be done under force circumstances
even in comparatively young age group or unmarried or nulliparous women.
2)
Total or subtotal hysterectomy: The preferred surgery is always a total
hysterectomy unless there is sufficient reason to leave behind the cervix. In
some cases subtotal hysterectomy is preferred such as
a) Difficult tubo ovarian mass with obliteration of anterior and
posterior pouches.
b) Pelvic endometriosis particularly
involving the rectovaginal septum.
c) Emergency hysterectomy.
·
Advantages of subtotal hysterectomy :-
1)
Reduced operative and post-operative morbidity.
2)
Reduced vaginal shortening and vault prolapse.
3)
Increased sexual satisfaction.
4)
Hospital stay is shorter.
·
Disadvantages of subtotal hysterectomy :-
1) Cervicitis with abnormal vaginal discharge.
2)
Stump carcinoma may develop.
·
Normally in total and subtotal hysterectomy ovaries are preserved but in
some cases it has to be removed such as :-
a) If the ovaries are
diseased with inflammatory process or involved in neoplastic conditions with
the patient around the age of 40 or older .
b) Hysterectomy done in women of any
age who has a history of ovarian or breast cancer in first degree relative.
c) Postmenopausal women as a routine.
·
Normally in total and subtotal fallopian tubes are preserved but in some
cases it has to be removed such as :-
a) When the ovaries are removed.
b) When the tubes are diseased but
ovaries are conserved (salpingectomy) due to young age.
·
COMPLICATIONS OF HYSTERECTOMY:-
1)
Intraoperative
a) Injury to the bladder
b) Injury to the ureters
c) Injury to the peritoneum
d) Primary haemorrhage:- It is due to
slipping of the ligature usually that of the vaginal angle. Haemotasis can be
achieved by the vaginal route under general anesthesia. If the procedure fails,
laprotomy has to be done.
e) Secondary haemorrhage:- This type
of haemorrhage occurs between 7 to 14 days after operation and is due to
sepsis. Bleeding source may be from the vault or internally from the sloughing
uterine or ovarian artery.
f) Internal haemorrhage:- which is
fortunately rare, laprotomy has to be done along with resuscitative procedures.
If the uterine artery is involved, anterior division of the internal iliac
artery has to be tied to secure haemostasis.
g) Anesthetic complications:-atelectasis,
pulmonary edema, embolism.
2)
Post-operative:-
a) Immediate:-Hypovolemia, shock,
urinary retention due to pain and spasm, cystitis, anuria due to inadequate
fluid replacement(prerenal) or ureteric obstruction .
b) Late:-Incontinence overflow due to
prolonged over distension of the bladder.
c) Stress:- due to prolonged
catheterisation.
d) Pyrexia:- Fever may be due to :
i) Cystitis
ii) Abdominal wound
infection
iii) Vault
cellulitis, haematoma
iv) Thrombophlebitis
v) Pulmonary
infection, atelectasis, pneumonia
vi) Peritonitis.
e) Haematomas- In the pelvis or
rectus sheath may cause low grade temperature .Large haematomas should be drained.
f) Wound dehiscence is seen commonly
with vertical incision. Patients with infection, immune suppression and malignancy
are at higher risk.
g) Paralytic ileus and intestinal
obstruction- Postoperative bowel dysfunction may be due to ileus or obstruction.
h) Necrotising fascitis is a rare but life threatening complication.
Infection is in the superficial and subcutaneous tissues. There is extensive
necrosis. Supportive therapy, wide tissue excision and antibiotics are the management.
i) Phlebitis -Intravenous cannula
related phlebitis causes pain, redness and fever .Venous cannula should be
removed and antibiotic should be continued.
j) Deep vein thrombosis:-it is an uncommon problem .Calf veins are
commonly affected .It is associated with low grade fever, pain and swelling of
the affected calf. B-mode ultrasound can detect an intramural clot. Heparin is
administered intravenously (30,000 to 40,000 units /24 hours ).once the
diagnosis is confirmed activated partial thromboplastin time is maintained at
1.5 to 2.5 times the control .Heparin is replaced by warfarin orally after 5
days .
i) Pulmonary embolism :- rare but fatal can be diagnosed by pulmonary angiography,
spiral CT ,Heparin is the drug of choice, recombinant human plasminogen
activator clear the emboli when infused Intravenously.
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